1376531210 NPI number — PHILIP B MENG CRNA

Table of content: PHILIP B MENG CRNA (NPI 1376531210)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376531210 NPI number — PHILIP B MENG CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENG
Provider First Name:
PHILIP
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376531210
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 EAST CARPENTER STREET
Provider Second Line Business Mailing Address:
ROOM 2K64
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62769-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-525-5643
Provider Business Mailing Address Fax Number:
217-544-2521

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 EAST CARPENTER STREET
Provider Second Line Business Practice Location Address:
ROOM 2K64
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62769-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-525-5643
Provider Business Practice Location Address Fax Number:
217-544-2521
Provider Enumeration Date:
10/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  041268080 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 209-005618 . This is a "IL APN LICENSE #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 46801 . This is a "AANA#" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: L031806 . This is a "CHAMPUS/TRICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 041268080 . This is a "IL LICENSE #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 0841504038 . This is a "BCBS OF ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 031304 . This is a "HEALTH ALLIANCE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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